title: No ring at all in mitral valve repair: indications, techniques and long-term outcome.
abstract: OBJECTIVE
  In mitral valve (MV) repair, we adhere to a biological concept of preservation of the native valves and avoidance of any prosthetic materials except for sutures whenever possible. Untreated autologous pericardium is the biological tissue of choice we use to support the repair. We report our 25-year institutional experience with no-ring MV repair in terms of indications, repair techniques and long-term results.
  
  
  METHODS
  Patients with ruptured chordae or posterior leaflet prolapse from degenerative MV disease, active infective endocarditis (IE), ischaemic mitral incompetence (IMI), annular dilatation with or without ruptured chordae along the posterior leaflet, and various lesions of the MV and its subvalvar apparatus underwent suture-repair techniques tailored to their valve morphology. These are personal series of modified Gerbode-Hetzer posterior leaflet plication and modified Paneth-Hetzer posterior annulus shortening techniques. Indications for the use of each technique and technical details are described in this report.
  
  
  RESULTS
  Modified Gerbode-Hetzer posterior leaflet plication: mean duration of the follow-up is 15.84±0.58 years. Overall freedoms from reoperation and cumulative survival rate are 55.4±4.7 and 44.7±5.4%, respectively. Freedom from reoperation is 83.5±4.3%, in ruptured chordae from degenerative disease (n=161), 74.4±10.1% in active infectious endocarditis (IE) (n=22) and 100% from both ruptured chordae of ischaemic origin (n=10) and deceleration trauma (n=1), respectively. Likewise, freedoms from reoperation at a mean duration of the follow-up of 11.2±7.2 years in 62 children stratified based on age groups are: <3 months: 61.4±2.7%; 3 months to 2 years: 78.7±3.7%; 2-18 years: 97.1±2.4%. Modified Paneth-Hetzer posterior annulus shortening: Mean duration of the follow-up is 11.98±1.14 years. Overall freedoms from reoperation and cumulative survival rate in 179 patients are 82.95±4.1 and 63.4±8.5%, respectively. Freedom from reoperation is 85.9±13.9% in patients with annular dilatation from any form of cardiomyopathy (n=81), 78.4±5.6% in those with IMI (n=75) and 100% in those who underwent asymmetric valve repair (n=23). In IMI, mean New York Heart Association functional class, ejection fraction and degree of mitral incompetence (MI) were significantly abated (P=0.001). In 78 children, freedoms from reoperation at a mean duration of the follow-up of 11.2±7.2 years stratified based on age groups are as follows: <3 months: 82.79±3.5%; 3 months to 2 years: 71.6±5.3%; 2-18 years: 85.1±4.4%.
  
  
  CONCLUSIONS
  No-ring MV repair using the aforementioned techniques in patients with MI resulting from chordal rupture, degenerative valve disease, IE, annular dilatation and posterior leaflet prolapse and from IMI as well as various MV lesions in children offers excellent long-term functional results with satisfactory freedom from reoperation.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany.
authors.forename: Roland
authors.initials: R
authors.lastname: Hetzer
authors.forename: Eva Maria
authors.initials: EM
authors.lastname: Delmo Walter
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000601:surgery*; D010496:Pericardium / Q000601:surgery; D016896:Treatment Outcome; D055815:Young Adult
keywords: Annuloplasty; Autologous pericardium; Mitral incompetence; Mitral valve; Posterior leaflet plication; Systolic anterior motion